Evolution in treatment strategy for metastatic spine disease: Presently evolving modalities

The advent of minimally invasive surgery (MIS) in the surgical management armamentarium and stereotactic radiosurgery in the domain of radiotherapy, has led to a major evolution in treatment of metastatic spine disease (MSD). We reviewed the recent literature to discuss evolution from open to MIS approaches in MSD and the concurrent evolution in radiotherapy. This will provide a sound base for further development and understanding of treatment paradigms in MSD. Literature review showed that evolution of surgery can be traced from inappropriate open surgery (i.e. laminectomy) to appropriate open (i.e. posterior instrumentation and decompression) and further to minimally invasive surgery. This transition was concurrent with the introduction of radiotherapy and its evolution in management of MSD. Evidence shows that presently, the best clinical outcomes are achieved by surgery with timely postoperative radiotherapy. To make surgery an appealing choice in MSD, surgical morbidity needs to be minimized when planning postoperative oncological treatment. MIS approaches have advantages such as early wound healing enabling early introduction of radiotherapy, reduced intraoperative blood loss and shortened hospital stay. Pain reduction and neurological improvement are comparable to open surgery. A multidisciplinary team approach including spinal surgeons, medical & radiation oncologists is mandatory, as the treatment options are constantly evolving. Advancement in radiotherapy with introduction of MIS can be a game-changer in MSD due to reduced peri-operative morbidity, allowing earlier postoperative radiotherapy/chemotherapy. We also provide our treatment algorithm which relies on clinical presentation and radiological appearance of spinal cord compression, providing an overview of treatment strategy.